CMS to Fine, Exclude Providers Who Repeatedly Abuse Medicare

CMS is cracking down on providers who repeatedly overbill Medicare and other federal health programs through civil fines and potential exclusion from the programs.

In a "change request" that took effect Jan. 15, CMS outlined new steps to identify and discipline "recalcitrant providers," or those who abuse the program and do not change their inappropriate behavior even after extensive education by Medicare contractors to do so.

Contractors have placed these providers on prepay medical review for years, which protects Medicare dollars on the front end but exhausts contractor resources that could be utilized in more productive oversight activities, according to CMS.

The change request updates the Medicare Program Integrity Manual by adding a section that formalizes the process for addressing repeat offenders. According to the CMS directive, recalcitrant providers will face penalties overseen by HHS' Office of Inspector General, including civil monetary penalties or exclusion from Medicare and state healthcare programs.

The change predates the release of Medicare physician payment data, which go into effect in March. The federal government said making Medicare physician reimbursement data publicly available could benefit the healthcare system in several ways, one being the identification of areas to root out waste.

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